Healthcare Provider Details

I. General information

NPI: 1487460952
Provider Name (Legal Business Name): MICHAEL MOSQUERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 W LIBERTY ST
WAUCONDA IL
60084-2452
US

IV. Provider business mailing address

41845 N VENN RD
ANTIOCH IL
60002-8252
US

V. Phone/Fax

Practice location:
  • Phone: 847-526-2151
  • Fax:
Mailing address:
  • Phone: 847-526-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209031202
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: